Name on card: <input autofocus="" type="text" name="name" id="credit_card_name"><br>
Credit card number: <input type="text" name="CCNo" id="credit_card_number"><br>
Expiry Date: <select name="CCExpiresMonth">
  <option value="01">01</option>
  <option value="02">02</option>
  <option value="03">03</option>
  <option value="04">04</option>
  <option value="05">05</option>
  <option value="06">06</option>
  <option value="07">07</option>
  <option value="08">08</option>
  <option value="09">09</option>
  <option value="10">10</option>
  <option value="11">11</option>
  <option value="12">12</option>
</select>
/
<select name="CCExpiresYear">
    <option value="2010">2010</option>
    <option value="2011">2011</option>
    <option value="2012">2012</option>
    <option value="2013">2013</option>
    <option value="2014">2014</option>
    <option value="2015">2015</option>
    <option value="2016">2016</option>
    <option value="2017">2017</option>
    <option value="2018">2018</option>
    <option value="2019">2019</option>
    <option value="2020">2020</option>
    <option value="2021">2021</option>
    <option value="2022">2022</option>
    <option value="2023">2023</option>
</select>
<br>
CVC: <input name="cvc">
<br>
<input type="reset" value="Reset">
<input type="submit" value="Submit" id="credit_card_submit">